Research Korner: Critical Appraisal

Critical Appraisal of ‘A mixed methods study to compare models of spirometry delivery in primary care for patients at risk of COPD’

Critical Appraisal of ‘A mixed methods study to compare models of spirometry delivery in primary care for patients at risk of COPD’               Walters et al (2007) argue that spirometry, or the process of measuring lung function on the basis and/or speed of air that can be inhaled or exhaled, is important in the diagnosis of chronic obstructive pulmonary diseases (COPD). The authors conducted a six-month long research for individuals who are at risk of COPD through comparing two models of spirometry delivery. The research aimed at evaluating and comparing the effectiveness of trained nurse (TN) spirometry and usual care (UC) spirometry models of delivery. Mixed methods were used as tied to a comparative design of research. In this report, a critical appraisal of the original research will be discussed based on the evaluation tool for mixed method studies developed by Health Care Practice Research & Development Unit (HCPRDU). It is aimed that this report would provide a detailed appraisal on the basis of implications of the study, randomisation, group comparability, clinical validity of outcomes and generalisability.                  Initially, there are a number of features of the study that is worth pointing out before conducting a detailed critical appraisal of the mixed method study. First, the figure illustrations of the study flow chart including the actual number of patients who are diagnosed using spirometry and the number of patients who refused spirometry makes it easier to follow the pathway of patients. Second, the figure illustration of the impact of spirometry on the diagnosis of COPD reflects a detailed comparison on the performance of the two models used. Third, the study reports baseline data in tabular form, making it easier to make comparisons between the subjects the two models used. Table 1, in fact, presents data at two endpoints. Fourth, the study also presents data of the patients’ reasons in accepting and declining spirometry in a tabular form for better understanding from the appraiser’s point of view. Fourth, the qualitative accounts of the general practitioners (GPs) regarding the spirometry delivery were also tabulated in two endpoints. Finally, the researchers accomplished approval of a study protocol from the Southern Health and Medical Human Research Ethics Committee and written consents are obtained from participating GPs.               The structured abstract helps in identifying the population wherein based on the eligible target population 531/904 patients underwent spirometry in the TN model and 87/1130 patients in the UC model. These are the target groups which represent at risk of COPD. Directly, one could realise that this may exclude a large number of otherwise eligible patients who could benefit from a spirometry intervention. Although the abstract hinted that the study was done in Australia, nevertheless, the problem is that it did not provide where in Australia in particular the study was conducted. Hence, it is likely that the incidence of COPD problems might be lower in this population than in any part of Australia where smoking rate is higher considering this age group. The aged group was identified as over 35 years. Notably, however, the identified potential difference does not result in the lack of clarity when it comes to the definition of the population. One should hold onto such point offered herein until later when I look at the applicability of the results to local population.                 With the objective to increase recognition of airflow obstruction in primary care, the intervention is described as visiting trained nurse as compared with optimised usual care. Importantly, the terms visiting nurse and usual care contain the potential for significant variations when it comes to the quality and extent of the roles they played in the various care setting not just in the primary care setting. Although one may think that the details are already presented in the proposal, what the authors could have done is to position the experimental and control interventions (Caracelli and Greene, 1997) by means of outlining the functions of visiting nurses and usual carers in relation to the study. Moreover, there are significant differences between the two interventions. In the TN spirometry model, practice staff resort in invitation for opportunistic testing and advertising at the request of GPs and addressing cost issues whereas in the UC spirometry model, spirometry testing was done in accordance to usual practice protocol and was discretely made public, which could have contributed to differential effects. Both model undergone basic training of spirometry under the guidance of a physiologist and respiratory specialist physician.      Further, it would be also necessary to note that the study deals with spirometry which has inherent limitations. Spirometry largely depends on patient cooperation and should be repeated at least three times (Miller et al, 2005). The spirometry test was consisted of three expiratory maneuvers which meets the criteria of the American Thoracic Society (ATS) requirements of acceptability and repeatability. However, it did not mention how many times spirometry test was conducted, jeopardising reproducibility in the process. While it is stipulated in the study that the spirometer used has an advantage of stability, inbuilt quality assurance features and grade classifications, one has to employ a pragmatic approach on the extent of expertise of the nurses and usual carers in utilising the spirometer. The training provided is inadequate and is evident by the incompetence of GPs to interpret the findings. A “semi-black box” approach was evident wherein the interventions provide the input and the investigators provide for the output (Sydenstricker-Neto, 1997).   When it comes to the outcomes, one has to place amount of responsibility on the authors as they establish the principal outcomes of the study and over what period of time they are to be measured (Greene and Caracelli 1997). Results of study include 9 out of 531 participants and 2 out of 87 participants in TN and UC model, respectively had a new doctor recorded COPD diagnosis which leads the author to conclude that there is a substantial increase in and improved spirometry performance in the opportunistic testing compared to the usual care. The question now is: Are these particular outcomes valid and meaningful? Important to note is the fact that opportunistic testing was performed on 531 participants in the TN model and 87 participants were tested in the UC model. It is in this sense that one can argue that there will be a fundamental difference when it comes to the outcomes considering the disparity on the number of tests conducted. Since the study is randomised, it would be critical to allocate interventions based on the sufficient number of subjects that could not be manipulated while also ensuring that both known and unknown confounding variables are evenly distributed. Admittedly, the authors know that there is selection bias evident.   Another issue refers to the clinical validity of the period over which it has been measured (Cook and Campbell, 1979; Stewart et al, 2008). For people who do not have a background on spirometry and its application, feasibility and quality, it could be very difficult to distinguish the significance of the study based on planned comparisons of the number of tests performed and the proportions of the eligible target group at risk of COPD in a period of 6 months. It would be much harder, nonetheless, on the part of appraisers to determine the degree of efficacy of spirometer based on the fact that opportunistic testing was done in 5 minutes for TN model but with no information given for UC model. Because the study is an open trial, one can figure that it would have been more credible if the authors could have tabulated the symptoms relating to COPD or perhaps what makes a patient eligible instead of the reasons for decline or acceptance for the purpose of addressing clinical validity. It is said in here that this should not be neglected, what the paper is trying to argue is that outcomes must be embedded on the comparisons of the effectiveness of TN and UC models. UC model, because it adhered into a specific protocol will basically lack in such a basis.   After practices were recruited, the authors made use of a random numbers table whereby practices are randomised to models for delivery of spirometry to patients in the target group at risk of COPD. The practices were recruited through a newsletter distributed in all practices Southern Tasmania to which 6 urban and 2 rural practices responded. Age, which is over 35 years, and ever smoked regularly are used as inclusion criteria, no exclusion criteria were detailed, making the criteria as vague. Vague due to the fact that the study did not point out any gender criterion but in Table 1 it reflects the percentage of male smokers in both TN and UC model. Assuming, that majority of the smokers are male still the study should have determined the characteristics of patients belonging to the target group based on gender. Evidence concerning the effect of the intervention is equivocal because of this reason. Nevertheless, the authors noted that both model conform to similar profiles for age, gender, current smoker status and smoking pack-year history.     The pragmatic nature of health services trials depended heavily on completion of follow up (Sale and Kevin, 2004; Dixon-Woods, n.d.). Intention to treat analysis indicates that the patients analysed in the groups to which they were randomised will still be analysed based on their original group. True enough, there are 190 (84%) patients who have consulted a GP by 3 months after spirometry in the TN model. There are 11, 9 and 19 new doctor-recorded airflow obstructions for participants without prior self-reported COPD, new doctor-recorded airflow obstruction and for participants with prior self-reported diagnosis of COPD. Somewhat typically, the details of the total number of patients diagnosed belonging to UC model are not given. There are, however, 2 participants with airflow obstruction received a new doctor-recorded diagnosis of COPD and 4 demonstrated airflow obstruction among those with a prior self-reported COPD diagnosis.     Statistical significance was set at the 5% level. The authors noted, however, that there was a significance difference between proportions of the estimated eligible target group population that underwent spirometry in practices in the TN model (58.7%) versus in practices in UC model (7.7%) overall. Such a difference to reach the clinical significance is debatable especially that the models are not treated equally. Of concern are the spirometry quality and the impact of spirometry on diagnosis of COPD and cost of spirometry in TN model. The evident imbalance could mean that the magnitude of effect would be even greater for the UC model because the imbalance does not favour the UC model. But in the case that the imbalance favours the TN model, then it will confound the study. The perceptions of the GPs best manifest this wherein GPs valued high quality spirometry and increased testing of patients at risk of COPD in the TN model.   The study has a virtue of being conducted in Australian healthcare context particularly in primary care setting. However, variations could exist in terms of where specifically the study will be conducted. One cannot assure that the competence of nurses and care assistants in conducting spirometer testing, and not the effectiveness of spirometer, as well as the competence of GPs in interpreting would be consistent among all the population. Yes, applicability is possible but one cannot ignore the fact that it could also be considered reductio ad absurdem. As the study could not confirm its universality, the authors maintain that the findings may not be generalisable to all primary practice. The burden of proof lies in the specificity of the setting and the interventions which make the study less applicable. As mentioned earlier, one of the inherent problems of the study is the exclusion of a larger group of eligible patients especially that the authors did not provide rationales of conducting the study in Southern Tasmania. Even so, a valid conclusion would be a certain subgroup could benefit from implementation of a local health policy based on the evidences presented in the study if the whole population would not benefit from the said study.       References   Caracelli, V J and Greene, J C 1997, ‘Crafting mixed-method evaluation design,’ in J C Greene and V J Caracelli (eds.), Advances in mixed-method evaluation: The challenges and benefits of integrating diverse paradigms, New Directions for Program Evaluation, No. 74., Jossey-Bass, San Francisco, CA, pp. 19-32.   Cook, T D and Campbell, D T 1979, ‘Validity,’ in T D Cook and D T Campbell. Quasi-experimentation: Design and analysis for field settings, Houghton Mifflin, Boston, MA, pp. 37-94.   Critical appraisal and using the literature, retrieved on 5 March 2009, from http://www.shef.ac.uk.   Dixon-Woods, M n.d., Integration of research based of mixed-methods, Department of Health Sciences, University of Leicester.   Evaluation tool for mixed method studies, HCPRDU, retrieved on 5 March 2009, from http://www.fhsc.salford.ac.uk.   Greene, J C and Caracelli, V J 1997, ‘Defining and describing the paradigm issue in mixed-method evaluation,’ In J C Greene and V J Caracelli (eds.), Advances in mixed-method evaluation: The challenges and benefits of integrating diverse paradigms. New Directions for Program Evaluation, No. 74, Jossey-Bass, San Francisco, CA, pp. 5-18.   Miller, M R, Crapo, R and Hankinson, J 2005, ‘General considerations for lung function testing,’ European Respiratory Journal, vol. 26, no. 1, pp. 153-161.   Sale, J E M and Brazil, K 2004, ‘A strategy to identify critical appraisal for primary mixed method studies,’ Quality and Quantity, vol. 38, no. 4, pp. 351-365.   Stewart, M, Makwarimba, E, Barnfather, A, Letourneau, N and Neufeld, A 2008, ‘Researching reducing health mixed method approaches disparities,’ Social Science and Medicine, vol. 66, no. 6, pp. 1406-1417.   Sydenstricker-Neto, J, 1997, Research Design and Mixed-Method Approach – A Hand-on Experience.

Critical Appraisal of ‘A mixed methods study to compare models of spirometry delivery in primary care for patients at risk of COPD’

Critical Appraisal of ‘A mixed methods study to compare models of spirometry delivery in primary care for patients at risk of COPD’ ...

A Critical Evaluation of Infection Control Practice

"A Critical Evaluation of Infection Control Practice"   INTRODUCTION   ICUs are the place in the hospital where the most severely ill patients are admitted, with the use of multiple invasive devices and frequent prescription of broad-spectrum antimicrobial agents. For these reasons, optimization of nursing-care procedures and adherence to antibiotic prescription rules are strongly recommended for the control of nosocomial infections. Most patients in these units require an indwelling urinary catheter to monitor diuresis. A closed drainage system is strongly recommended to prevent catheter-associated urinary tract infections. However, to our knowledge, no comparative trial comparing open and closed drainage systems has been conducted in ICU patients. This paper aims to examine the current practices of ICUs in hospitals in the procedure of catheterization and the role of the nurses. It also aims to provide recommendations after researching into the current conditions and infection control procedures.   BODY               Nosocomial infections (NIs) are hospital-born infections and now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to intensive care units (ICUs) (2004). Infection after urinary catheterization is one example. Each year, urinary catheters are inserted in more than 5 million patients in acute-care hospitals and extended-care facilities. Urinary tract infections are the second most common nosocomial infections in ICUs in Europe and the first in the United States (2001). Catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection in hospitals and nursing homes, comprising [is greater than] 40% of all institutionally acquired infections. Nosocomial bacteriuria or candiduria develops in up to 25% of patients requiring a urinary catheter for [is greater than or equal to] 7 days, with a daily risk of 5%. CAUTI is the second most common cause of nosocomial bloodstream infection, and studies by Platt et al. and Kunin et al. suggest that nosocomial CAUTIs are associated with substantially increased institutional death rates, unrelated to the occurrence of urosepsis ( 2001). For centuries, the urethral catheter system consisted of a tube inserted through the urethra into the bladder and drained into an open container. The closed catheter system was developed in the 1950s and is still in use today (2000). UTIs are the most common nosocomial infection, accounting for 40% of all hospital-reported infections and affecting approximately 600,000 patients annually. Catheter insertion is the primary risk factor for nosocomial UTIs. Women and elderly patients are at increased risk for catheter-associated UTIs, but several other risk factors exist. Pre-existing chronic illness, malnutrition, diabetes, renal insufficiency, and insertion of the catheter outside the operating room or late in hospitalization are each associated with increased risk of UTIs. (1,3) In addition to causing morbidity, UTIs also contribute directly to mortality in approximately 0.1% of patients annually in the United States. UTIs also add to the costs of care by prolonging hospitalization by 1 to 4 days and increasing the direct costs of treatment by an estimated $593 to $680 per infection (2005). They may involve a urosepsis, which carries a mortality rate that may be as high as 25 to 60%. They often occur in patients with an indwelling urinary catheter. The lumen and external surfaces of the catheter are the routes for bacterial entry into the bladder. For preventing infection, the maintenance of a closed sterile drainage system is described as the most successful method. A closed drainage system was described for the first time in 1928, and its benefit was appreciated much later (2001). Although most CAUTIs are asymptomatic, rarely extend hospitalization, and add only $500 to $1,000 to the direct costs of acute-care hospitalization, asymptomatic infections commonly precipitate unnecessary antimicrobial-drug therapy. CAUTIs comprise perhaps the largest institutional reservoir of nosocomial antibiotic-resistant pathogens, the most important of which are multidrug-resistant Enterobacteriacae other than Escherichia coli, such as Klebsiella, Enterobacter, Proteus, and Citrobacter; Pseudomonas aeruginosa; enterococci and staphylococci; and Candida spp (2001). Excluding rare hematogenously derived pyelonephritis, caused almost exclusively by Staphylococcus aureus, most microorganisms causing endemic CAUTI derive from the patient's own colonic and perineal flora or from the hands of health-care personnel during catheter insertion or manipulation of the collection system. Organisms gain access in one of two ways (Figure 1). Extraluminal contamination may occur early, by direct inoculation when the catheter is inserted, or later, by organisms ascending from the perineum by capillary action in the thin mucous film contiguous to the external catheter surface. Intraluminal contamination occurs by reflux of microorganisms gaining access to the catheter lumen from failure of closed drainage or contamination of urine in the collection bag (2001) Catheterization of the bladder involves introducing a rubber or plastic tube through the urethra and into the bladder. The catheter provides a continuous flow of urine in patients who are unable to control micturition or those with obstructions. It also provides a means of assessing urine output in hemodynamically unstable clients. Because bladder catheterization carries the risk of urinary tract infections, blockage, and trauma to the urethra, it is preferable to rely on other measures for either specimen collection or management of incontinence (2004).             The use of urinary catheters should be avoided whenever possible. Clean intermittent catheterization, when practical, is preferable to long- term catheterization. Suprapubic catheters offer some advantages, and condom catheters may be appropriate for some men. While clean handling of catheters is important, routine perineal cleaning and catheter irrigation or changing are ineffective in eliminating bacteriuria. Bacteriuria is inevitable in patients requiring long-term catheterization, but only symptomatic infections should be treated. Infections are usually polymicrobial, and seriously ill patients require therapy with two antibiotics. Patients with spinal cord injuries and those using catheters for more than 10 years are at greater risk of bladder cancer and renal complications; periodic renal scans, urine cytology and cystoscopy may be indicated in these patients ( 2000). Once the decision has been made to use an indwelling urinary catheter, efforts should be made to minimize problems.   Recommendations               Build up of secretions or encrustation at the catheter insertion site is a source of irritation and potential infection. The nurses, in order to avoid such a situation, must provide perineal care and hygiene at least twice daily or as needed for a patient with a retention catheter. Soap and water are effective in reducing the number of organisms around the urethra. The nurse must not accidentally advance the catheter up into the bladder during cleansing or risk introducing bacteria.             In addition to routine perineal care and hygiene, many institutions recommend that clients with catheters receive special care at least three times a day and after defecation or bowel incontinence to help minimize discomfort and infection.             All patients with catheter should have a daily fluid intake of 2000 to 2500 ml if permitted. This can be met through oral intake or intravenous infusion. A high fluid intake produces a large volume of urine that flushes the bladder and keeps catheter tubing free of sediment.             Maintaining a closed urinary drainage system is important in infection control. A break in the system can lead to introduction of microorganisms. Sites at risk are the site of catheter insertion, the drainage bag, the spigot, the tube junction, and the junction of the tube and the bag.             In addition, the nurse has the responsibility to monitor the patency of the system to prevent pooling of urine within the tubing. Urine in the drainage bag is an excellent medium for microorganism growth. Bacteria can travel up drainage tubing to grow in pools of urine. If this urine flows back to the patient’s bladder, an infection will likely develop.             Suggestions for ways to prevent infections in catheterized patients are the following: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Follow good hand hygiene techniques.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Do not allow the spigot on the drainage system to touch a contaminated surface.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Only use sterile technique to collect specimens from a closed drainage system.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> If the drainage tube becomes disconnected, do not touch the ends of the catheter or tubing. Wipe the end of the tubing and catheter with an antimicrobial solution before reconnecting.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Ensure that each client has a separate receptacle for measuring urine to prevent cross contamination.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Prevent pooling of urine in the tubing and reflux of urine into the bladder.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Avoid raising the drainage bag above the level of the bladder.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> If it becomes necessary to raise the bag during transfer of a patient to a bed or stretcher, clamp the tubing or empty the tubing contents to the drainage bag first.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Provide for drainage of urine from the tubing to the bag by positioning the tubing.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Empty the drainage bag at least every 8 hours. If large outputs are noted, empty more frequently.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Encourage fluid intake, if it is not contraindicated. Inclusion of cranberry juice has been shown to decrease the adherence of bacteria to the bladder wall and to catheter lumen.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Remove the catheter as soon as clinically warranted.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Tape or secure the catheter appropriately for the patient.</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Perform routine perineal hygiene per agency policy and after defecation r bowel incontinence.</li> </ul>               Good health depends in part on a safe environment. Practices or techniques that control or prevent transmission of infection help to protect individuals, especially patients and health care workers from disease. Patients in all health care settings are at risk for acquiring infections because of lower resistance to infectious microorganisms, increased exposure to numbers and types of disease-causing microorganisms, and invasive procedures.             In acute care or ambulatory care facilities, patients can be exposed to pathogens, some of which may be resistant to most antibiotics. By practicing infection prevention and control techniques, health care workers can avoid spreading microorganisms to patients and fellow health care workers.             In all settings, the patients and their families must be able to recognize source of infections and be able to institute protective measures. Patient teaching should include information concerning infections, modes of transmission, and methods of prevention. The first major advance for preventing CAUTI since the wide-scale adoption of closed drainage 35 years ago is the development of catheters with antiinfective surfaces. These advances should not be considered the final answer, however. Other technologies that should be pursued include new, more potent antiinfective materials; microbe-impervious antireflux valves; urethral stents; conformable (collapsible) urethral catheters; and vaccines for enteric gram-negative bacilli and staphylococci. Antiseptics are far more likely than antibacterials to confer greater resistance to surface colonization and not to select for infection with antimicrobial-drug resistant bacteria or yeasts. New surface technologies that release far greater quantities of ionic silver or other antiinfective agents into the aqueous environment contiguous to the catheter surface might even prevent CAUTIs caused by intraluminal contaminants (2001). Prevention of catheter-associated UTIs is more effective, particularly for indwelling catheters, than relying solely on antimicrobial agents. (8) The most effective practice interventions for reducing catheter-associated UTIs include identifying patients who no longer need indwelling catheters, considering other catheterization options or alternatives to catheterization, and providing patient and caregiver education when long-term indwelling catheterization is needed (2005). Reducing the time a patient is catheterized can be accomplished by systematic reminders to review the duration of catheterization for each patient. An interventional study in which physicians were reminded daily to remove unnecessary catheters significantly reduced the number of catheter days from 7 to 4.6 (P<0.001), which reduced the rate of catheter-associated UTIs from 11.5 to 8.3 per 1000 catheter-days (P=0.009). This intervention also resulted in a 69% decrease in the monthly cost of antibiotics for catheter-associated UTIs. Reminders to remove unnecessary catheters can be issued by the nursing staff or by computerized ordering systems (2005). In addition to practice intervention, the choice of catheters and related equipment can also reduce UTIs substantially. Other methods of catheterization should he considered before inserting an indwelling catheter. Catheterization options are based on the reason for catheterization and the expected duration of need. Other options include condom catheters for males, suprapubic catheters for patients who require long-term indwelling drainage, and intermittent catheterization for patients with spinal cord injuries. (3,7) Patients who must use an indwelling catheter should have a closed catheter system with a small catheter (14 to 18 French with a 5-cc balloon). Manufacturer's recommendations for inflation and deflation, system maintenance, securing the catheter, and properly positioning the drainage bag below the patient's bladder should be followed. Preventing encrustation and blockage are also very important. Following these steps and properly maintaining closed drainage catheter systems has been shown to substantially reduce the risk for UTI (2005).     CONCLUSION               Patient safety should be the number one concern before, during and after each procedure in any hospital. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. In my area of work, the principles of general preventive measures such as the implementation of standard and isolation precautions should be reviewed. Urinary catheterization can cause many health problems. Alternatives to catheterization should be used whenever possible. Reduction of catheter-associated UTIs is based primarily on preventive infection control practices. The cornerstones of effective prevention include thorough adherence to the guidelines promoted by the CDC for hand hygiene, correct insertion, handling, positioning, and maintenance of catheters; avoidance or limited use of long-term indwelling catheters; and possibly selection of catheters that are designed to deter biofilm growth. Following appropriate practice and product interventions, it is possible to significantly reduce the number of catheter-associated UTIs. This, in turn, reduces hospital stays and associated costs of treatment. The greatest hope for a major reduction in CAUTI and indeed all nosocomial infections is likely to be vaccines against important nosocomial multidrug-resistant pathogens, such as the enteric gram-negative bacilli and staphylococci. The success of the nurse who practices infection-control techniques is measured by determining whether the goals for reducing or preventing infection are achieved. A comparison of the client’s response, such as absence of fever or development of wound drainage, with expected outcomes determines the success of nursing interventions.

A Critical Evaluation of Infection Control Practice

"A Critical Evaluation of Infection Control Practice" INTRODUCTION ICUs are the place in the hospital where the mos...

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